HospitalInspections.org

Based on observation and interview, the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This deficient practice would affect approximately 1 of 5 wings within the facility. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/18/15, at 11:25 a.m., revealed a hole around the chilled water pipe located on the Upper A Floor.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This deficient practice would affect approximately one of five smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings include:
Observations and staff interviews on 01/28/15 at 2:04 p.m., revealed a gap (greater than 1/2 inch) between the door and door frame on the door to IT Receptionist Office.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This deficient practice would affect approximately 3 of 5 zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings include:
1. Observations and staff interviews on 01/28/15 at 09:12 a.m., revealed the door to the Soiled Linens Room located on the First Floor was not equipped with door closing hardware.
2. Observations and staff interviews on 01/28/15 at 09:14 a.m., revealed the door to the Old Sewing Room located on the First Floor was not equipped with door closing hardware.
3. Observations and staff interviews on 01/28/15 at 10:21 a.m., revealed the door to Storage Room B 19 on Level A was not equipped with door closing hardware.
4. Observations and staff interviews on 01/28/15 at 11:23 a.m., revealed the door to the Acute Storage Room on Upper Level A was not equipped with door closing hardware.
5. Observations and staff interviews on 01/28/15 at 11:25 a.m., revealed the door to the Elevator Maintenance Room on Upper Level A was not equipped with door closing hardware.
6. Observations and staff interviews on 01/28/15 at 11:29 a.m., revealed the door to the B Elevator Maintenance Room on Upper Level A was not equipped with door closing hardware.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits that are easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect the entire facility. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 01/27/15 at 1:45 p.m., revealed items being stored in the path of egress for the Kitchen.
2. Observations and staff interviews on 01/27/15 at 2:00 pm, revealed the East Exit Door for the 3rd floor was chained and padlocked shut.
3. Observations and staff interviews on 01/28/15 at 09:12 a.m., revealed items being stored in the exit passage way located by the Physical Therapy Room on the First Floor.
4. Observations and staff interviews on 01/28/15 at 10:45 p.m., revealed a deadbolt lock on the Exit Door located by the M.R.I. Dock.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This would effect 1 of 5 smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 10:48, revealed the emergency light located in the Trauma Room on Level A did not illuminate when tested.
Maintenance Staff A verified this observation.

Based on record review, observation and interview, the facility failed to provide a fire alarm system that provided proper activation and annunciation that was installed in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition and Sections 19.3.4 and 9.6 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect one of five smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 10:44, revealed a smoke detector that was mounted within 36 inches on a HVAC vent that was located in the M.R.I Room on Level A.
Maintenance Staff Averified this observation.

Based on observation and interview, the facility failed to provide proper portable fire extinguishers within the facility that were in accordance with the National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition and Section 19.3.5.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect one of five zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 8:15 p.m., revealed the fire extinguisher located on the 1st Floor by Receiving was mounted higher than 72 inches (5 feet) above the floor.
Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility failed to provide proper protection for the commercial cooking equipment in accordance with Sections 19.3.2.6 and 9.2.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and the NFPA Standard 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice would effect 1 of 5 smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations record review and staff interviews on 01/27/15 at 11.02 a.m., revealed the facility did not have documentation for two inspections of the hood system located in the Kitchen.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in 4 of 5 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 01/27/15 at 13:45, revealed items being stored within 36 inches of the electric panel located by the Kitchen Exit and in the Air Handling Room on Level A.
2. Observations and staff interviews on 01/28/15 at 08:15 a.m. and 11:19 a.m., revealed a fan plugged into a surge protector located in the #1 Business Office on the First Floor and in the HIM Room on the B Level.
3. Observations and staff interviews on 01/28/15 at 10:18 a.m., revealed a coffee maker and microwave plugged into a surge protector located in the West Central Ortho on Level A.
4. Observations and staff interviews on 01/28/15 at 10:58 , revealed exposed wires under the electric panel EMPP located in the Mechanical Room and above the air compressor located in the Mechanical Room on Level B.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This deficient practice would affect approximately 1 of 5 wings within the facility. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/18/15, at 11:25 a.m., revealed a hole around the chilled water pipe located on the Upper A Floor.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This deficient practice would affect approximately one of five smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings include:
Observations and staff interviews on 01/28/15 at 2:04 p.m., revealed a gap (greater than 1/2 inch) between the door and door frame on the door to IT Receptionist Office.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This deficient practice would affect approximately 3 of 5 zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings include:
1. Observations and staff interviews on 01/28/15 at 09:12 a.m., revealed the door to the Soiled Linens Room located on the First Floor was not equipped with door closing hardware.
2. Observations and staff interviews on 01/28/15 at 09:14 a.m., revealed the door to the Old Sewing Room located on the First Floor was not equipped with door closing hardware.
3. Observations and staff interviews on 01/28/15 at 10:21 a.m., revealed the door to Storage Room B 19 on Level A was not equipped with door closing hardware.
4. Observations and staff interviews on 01/28/15 at 11:23 a.m., revealed the door to the Acute Storage Room on Upper Level A was not equipped with door closing hardware.
5. Observations and staff interviews on 01/28/15 at 11:25 a.m., revealed the door to the Elevator Maintenance Room on Upper Level A was not equipped with door closing hardware.
6. Observations and staff interviews on 01/28/15 at 11:29 a.m., revealed the door to the B Elevator Maintenance Room on Upper Level A was not equipped with door closing hardware.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits that are easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect the entire facility. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 01/27/15 at 1:45 p.m., revealed items being stored in the path of egress for the Kitchen.
2. Observations and staff interviews on 01/27/15 at 2:00 pm, revealed the East Exit Door for the 3rd floor was chained and padlocked shut.
3. Observations and staff interviews on 01/28/15 at 09:12 a.m., revealed items being stored in the exit passage way located by the Physical Therapy Room on the First Floor.
4. Observations and staff interviews on 01/28/15 at 10:45 p.m., revealed a deadbolt lock on the Exit Door located by the M.R.I. Dock.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This would effect 1 of 5 smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 10:48, revealed the emergency light located in the Trauma Room on Level A did not illuminate when tested.
Maintenance Staff A verified this observation.

Based on record review, observation and interview, the facility failed to provide a fire alarm system that provided proper activation and annunciation that was installed in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition and Sections 19.3.4 and 9.6 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect one of five smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 10:44, revealed a smoke detector that was mounted within 36 inches on a HVAC vent that was located in the M.R.I Room on Level A.
Maintenance Staff Averified this observation.

Based on observation and interview, the facility failed to provide proper portable fire extinguishers within the facility that were in accordance with the National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition and Section 19.3.5.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect one of five zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 01/28/15 at 8:15 p.m., revealed the fire extinguisher located on the 1st Floor by Receiving was mounted higher than 72 inches (5 feet) above the floor.
Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility failed to provide proper protection for the commercial cooking equipment in accordance with Sections 19.3.2.6 and 9.2.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and the NFPA Standard 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice would effect 1 of 5 smoke zones. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
Observations record review and staff interviews on 01/27/15 at 11.02 a.m., revealed the facility did not have documentation for two inspections of the hood system located in the Kitchen.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in 4 of 5 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 residents and a census of 12 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 01/27/15 at 13:45, revealed items being stored within 36 inches of the electric panel located by the Kitchen Exit and in the Air Handling Room on Level A.
2. Observations and staff interviews on 01/28/15 at 08:15 a.m. and 11:19 a.m., revealed a fan plugged into a surge protector located in the #1 Business Office on the First Floor and in the HIM Room on the B Level.
3. Observations and staff interviews on 01/28/15 at 10:18 a.m., revealed a coffee maker and microwave plugged into a surge protector located in the West Central Ortho on Level A.
4. Observations and staff interviews on 01/28/15 at 10:58 , revealed exposed wires under the electric panel EMPP located in the Mechanical Room and above the air compressor located in the Mechanical Room on Level B.
Maintenance Staff A verified these observations.